Legislation

Patient Group Directions (PGDs) do not give a legal framework for healthcare professionals to adjust a dose of medicine already in a person’s possession, and must not be used for this purpose.

Local mechanisms for titration of medication dosages

Some medicines require doses to be titrated or adjusted according to the individual’s response, such as insulin or diuretics. The requirement to adjust the dose needs to be implicit in the prescription for the medicine.

Written protocols

Appropriately trained and competent healthcare professionals may use locally produced and approved written protocols to advise individuals to adjust the dose of their medication, if required to maintain optimum treatment. Template protocols should be produced by the specialist team, including those who prescribe and those with a specialist clinical knowledge of the medication. It is advised that the protocol should be individualised for each patient, by a specialist clinician with knowledge of the individual. The protocol should include all necessary parameters, including maximum dose for the individual and time scale for titration.

Considerations

Written protocols have no legal standing in respect of medicines legislation and are subject to local agreements between healthcare professionals and their organisations. Consideration must be given to the required training, clinical governance and local authorisation of such protocols. This is to ensure that they comply with the organisation’s governance processes and support the safe and effective management medications.

It is likely that written protocols covering advice on dosage adjustment would reflect many of the principles governing PGDs. Consideration should be given to how medications are labelled when the dose is amended under such a written protocol, to ensure individuals/carers are fully aware of dosage changes. How advised dosage adjustments are recorded in all records (including medication administration record (MAR) charts and clinical records) should also be considered.

Independent prescribing

Organisations may need to consider the role of independent or supplementary prescribers within pathways where medication dose adjustments are routinely required, and if this would allow more individualised care.

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